CDPH Licensing & Enforcement

The California Department of Public Health (CDPH) Licensing and Certification surveyors may visit a hospital at any time to determine whether the hospital is in compliance with state licensing requirements. Visits may result from a complaint by a patient, employee or other third party; a newspaper article; or a report by the hospital itself regarding an unusual occurrence, privacy breach or adverse event.

The California Department of Public Health (CDPH) Licensing and Certification surveyors may visit a hospital at any time to determine whether the hospital is in compliance with state licensing requirements. Visits may result from a complaint by a patient, employee or other third party; a newspaper article; or a report by the hospital itself regarding an unusual occurrence, privacy breach or adverse event.

If surveyors find a violation of state law, they issue a statement of deficiencies, and the hospital is required to submit a plan of correction to CDPH. Under new regulations that went into effect April 1, 2014, CDPH may fine hospitals for state licensure violations that place patients in “immediate jeopardy” (IJ) of serious injury or death, as well as violations that do not rise to that level. Additional information on these new regulations is available for members at www.calhospital.org/cha-news-article/new-administrative-penalties-take-effect-april-1.

CDPH has announced approximately $10.6 million in fines on hospitals for IJ violations since the department was given that authority by SB 1312 in January 2007. As a result of the new regulations, fines levied against hospitals are expected to markedly increase.

The California Department of Public Health (CDPH) has issued the attached All Facilities Letter noting current outbreaks of hepatitis A infection in San Diego and Santa Cruz counties. According to CDPH, infections are particularly prevalent among homeless persons and users of illicit drugs. CDPH has determined transmission occurs person-to-person; no commercial product is identified as being contaminated.

CDPH recommends that hospitals work with local health departments to offer hepatitis A vaccines to all patients who are homeless, users of injection or non-injection illicit drugs, infected with hepatitis B or hepatitis C, or have other liver disease. Hospitals must contact their local health department immediately – while the patient is still in the facility – to report suspected hepatitis A infections, as well as promptly report all confirmed cases and save the blood (serum and EDTA or citrate plasma) from hepatitis A serological testing. Providers in outbreak jurisdictions should also make the hepatitis A vaccine available to health care personnel who have frequent close contact with patients who are homeless or use illicit drugs.

The California Department of Public Health’s Center for Health Care Quality will host its semi-annual stakeholder forum on Aug. 17 from 1-2:30 p.m. (PT). The forum is scheduled to provide updates on Licensing & Certification Program activities, including a performance metrics update, Hubbert recommendation updates, and discussion of 3.5 staff direct care hours regulations as well as the Quality Accountability Supplemental Payment Program. The session will also include time for general questions and answers. More information is available on the Stakeholder Forum web page.

If a symptomatic patient has no identifiable Zika exposure, providers should contact their local health department. Providers should remind patients who want to conceive in the near future, and who have an ongoing risk of Zika exposure, of recommendations to delay pregnancy until exposure can be reduced. Preconception patients should also consider immunoglobulin M testing to establish a baseline to inform future Zika test results, should the patient be exposed in an ensuing pregnancy.

The California Department of Public Health this week launched its redesigned website, including improvements to the Center for Health Care Quality’s Licensing and Certification Program pages. The site aims to highlight the work of public health and promote the department’s protection of California health and wellness. The old site, which has been archived and will be taken down in the next few months, is available at https://archive.cdph.ca.gov/Pages/DEFAULT.aspx.

The California Department of Public Health (CDPH) has issued the attached All Facilities Letter updating its previous guidance related to reporting emergency and disaster occurrences that threaten the welfare, safety or health of patients. The updated guidelines provide contact information for reporting an emergency that results in patient evacuation, transfer or discharge. During normal business hours, facilities are reminded to report to their local CDPH Licensing & Certification district office. After hours, or if the district office is non-operational, facilities should contact the Office of Emergency Services Warning Center or, if in Los Angeles County, the Los Angeles County Operator.

The California Department of Public Health has issued the attached All Facilities Letter requesting comments on criminal record clearance regulations for certified nurse assistants and home health aides. The regulations are intended to implement procedures for processing criminal record clearances for these providers. Comments should be submitted by close of business on May 22.

The California Department of Public Health Center for Health Care Quality has released quarterly performance metrics on long-term care facilities and — for the first time — non-long-term care facilities, including general acute hospitals. The reports provide data through Sept. 30, 2016, on facility complaints, entity-reported incidents and relicensure surveys.

The California Department of Public Health has released the attached All-Facilities Letter outlining compliance requirements for licensed primary care clinics (PCCs) under AB 2053 (Chapter 639, Statutes of 2016), which took effect Jan. 1. AB 2053 established consolidated licensure for PCCs, allowing eligible clinics to add additional physical plants to their current license maintained and operated on separate premises. A PCC or affiliate clinic may add additional locations that are no more than one-half mile from the licensed clinic adding the additional physical plant. A licensing fee is required for each additional physical plant approved on the license. For more information, see the attached letter.

The California Department of Public Health (CDPH) Licensing and Certification (L&C) program earlier this year implemented a new general acute care hospital relicensing survey, intended to evaluate facility compliance with statutory and regulatory requirements addressed in Title 22 and the Health and Safety Code. CDPH has reissued the relicensing survey protocol with several changes.

Focused on quality of care, the survey will consist of a review of nursing and pharmacy as well as identified past compliance concerns. L&C will review three years of past compliance, including deficiencies and associated plans of correction — all of which could be areas of emphasis during the survey. Hospitals should be prepared to provide a full list of services and locations to the survey team, including outpatient services, and should review all past compliance issues (including 2567s, plans of corrections, etc.) as well as every complaint, entity-report incident and breach of medical information reported. To help hospitals better understand the survey process, CHA hosted a webinar, available for purchase, on the upcoming changes and has developed the California Hospital Survey Manual. Hospitals are encouraged to review information about the survey on the CDPH website.

Overview

You’ve received a licensing violation. You may have been expecting it from a recent survey, or it may have come as a complete surprise. One thing is for certain, survey activity — and subsequent violations — will be more common now that California Department of Public Health (CDPH) has issued new regulations for hospital penalties, including non-immediate jeopardy violations.

Overview

The surveyors have arrived, unannounced, at your hospital. What do you do first? What will the surveyors do?

The California Hospital Survey Manual can help hospitals prepare for the survey process, and explains who the surveyors are and how they conduct their surveys. It covers the different types of surveys and possible outcomes, and: